- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $3,890.45 / $9,772.37
| Facility | | $912.01 | $3,890.45 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $446.68 / $912.01
| Professional | | $371.54 | $446.68 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $7,413.10 / $15,135.61
| Facility | | $2,884.03 | $7,413.10 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $467.74 / $1,071.52
| Professional | | $323.59 | $467.74 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,548.82 / $4,168.69
| Facility | | $758.58 | $1,548.82 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $676.08 / $1,479.11
| Professional | | $436.52 | $676.08 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,495.41 / $12,302.69
| Facility | | $1,905.46 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $549.54 / $1,000.00
| Professional | | $371.54 | $549.54 | $1,000.00 |